Are you female ordering for yourself?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

How have you determined that you are suffering from Bacterial Vaginosis (BV)?

positive BV home self-test result
diagnosed by my GP or a clinic
self-diagnosis without a test
I am not suffering from BV

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Which of the following symptoms are you experiencing? Please tick ALL the symptoms that apply to you:

thin, greyish white discharge
white odourless discharge
offensive (fishy) smell of the discharge
vaginal soreness and itching
pain in the lower abdomen/pelvis
fever
abnormal bleeding

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you have any other discharge or symptoms?

Yes No

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you suffered from BV in the past 6 months?

Yes No

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you pregnant or breastfeeding or planning to become pregnant or start breastfeeding?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you suffer from any of the following?

Yes No

liver or kidney disease;
nervous system disease;
history of inflammatory bowel disease or antibiotic-associated colitis;
epilepsy or you have ever had fits;
porphyria ;
blood or blood cells disorder;
have been exposed to STD (Sexually transmitted disease);
any other chronic condition that we should know about;

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any of the following medications?

Yes No

anticoagulants (warfarin);
epilepsy medication (phenytoin, phenobarbitone);
cimetidine (to treat stomach ulcer);
5-fluorouracil or busulfan to treat cancer;
ciclosporin;
disulfiram (to treat alcoholism);
oestrogen contraceptive;
lithium;
erythromycin, lincomycin or any other antibiotics;

Please specify which of the medicine(s) above you are taking and their dosage

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any other medication not mentioned in the question above?

Yes No

Please provide the name, dosage and the reason why you are taking that medication or medications.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you allergic to Metronidazole, Dalacin (clindamycin), lincomycin or any of the other ingredients contained in BV medicines?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you drink alcohol?

Yes No

Select atleast one option

Do you understand that you should not drink alcohol while taking Metronidazol/Zidoval and for 48 hours after finishing the treatment as this may have very unpleasant side effects?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

In order for us to prescribe you with oral antibiotics (Metronidazole only), we are required to inform your regular GP. Do you give us consent to inform your GP about the supply of this medication?

Yes No

Please enter your GP's full name and surgery address so we can contact them to advise of the medication you have ordered.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you aware of the following?

Yes No

if you develop severe, prolonged or bloody diarrhoea during or after using Dalacin Cream you need to inform your doctor ;
sexual intercourse during treatment with Dalacin Cream is not recommended;
Dalacin Cream may weaken condoms and diaphragms. Do not rely on condoms or contraceptive diaphragms when using this medicine. The use of other vaginal products such as tampons or douches (vaginal washes) during treatment with the cream is not recommended;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

you have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health;
you will seek immediate medical attention if your symptoms worsen or not subside after you have finished your treatment;
you will inform your doctor about any unusual side effects;
the treatment is solely for your own use;
you will read the patient information leaflet supplied with your medication;
you will not exceed the maximum daily dose of this medication ;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

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I confirm that I am over 18 and I agree to the Terms and Conditions and the Privacy Policy.

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Medical Assessment